Skip to content

Patients › Wrist

Hook of Hamate Fracture

PDF Evidence
Updated Oct 2026
Illustration: wrist

What you're feeling

A hook of hamate fracture happens in a moment. The usual cause is a direct blow to the palm side of your hand, near the base of your little finger. This injury is common in baseball players and golfers, where a bat, club or racquet presses hard into that spot. A sudden force through the ligaments and tendons of the palm can also cause it.

Straight away, you feel pain on the palm side of your hand, at the base near your little finger. The spot is tender to touch. In most acute fractures, this tenderness is present every time. Pushing or pulling with your hand hurts, so gripping a doorknob, holding a coffee mug or twisting a jar lid becomes difficult. You may notice swelling. The pain is sharp at first, then settles to a deep ache.

The first days and weeks can be frustrating. Your hand hurts when you use it, and the ache can disturb your sleep early on. This injury is rare, and it often does not show up on standard wrist x-rays. That means it can be missed at first, especially when the x-rays look normal. If your symptoms match this pattern, a special x-ray view or a CT scan can find the fracture. A CT scan is very accurate for this injury.

Some warning signs need urgent care. Go to the emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever. Go the same day if you have broken skin over the injury, bone showing, or an obvious deformity. Go the same day if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement.

See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department.

What's actually happening

Deep inside your wrist, on the palm side, sits a small curved bone called the hamate. It has a little hook of bone pointing forward into your palm. That hook is a anchor point for some of the ligaments and muscles that move your little finger, and your finger tendons glide right against it when you grip.

When you fall onto your hand or swing a bat, club or racquet, that hook takes the strain. A single hard hit can crack it. Repeating the same swing thousands of times can also wear it down until it breaks, the way a paperclip snaps after being bent back and forth. This bone is small, and only about 2% of wrist bone fractures happen here.

The hook has a poor blood supply, and that matters. Bone needs blood to knit back together, like any other tissue. The hook also moves when you grip, because the tendons pressing on it keep the broken ends shifting. A fracture that keeps moving, with little blood flow, often struggles to heal. Doctors call this a nonunion, meaning the bone never knits.

If the broken pieces sit in their normal position, the bone can still knit if the hand is kept still early on. If the pieces have shifted apart, or the fracture is found late, simple healing becomes less likely. In that case, treatment usually means either holding the bone together with a small screw, or removing the hook altogether. Removing it sounds drastic, but the hand copes well without this small hook, and many people return to their sport at their previous level.

One more thing worth knowing. The rough, unhealed edge of a broken hook sits right against your finger tendons. Over time it can fray them, like a rope rubbing on a sharp rock. If a tendon snaps, the broken hook is removed and smoothed so the tendon can work again.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some hook of hamate fractures heal without an operation, and others need surgery soon, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic, we take a history, examine your hand, and arrange imaging where it is needed. Because this fracture often hides on standard x-rays, we may use a special x-ray view or a CT scan to see it clearly.

If the broken pieces sit in their normal position and the fracture is found early, we may hold your hand still in a splint or cast so the bone can knit. We keep an eye on healing with repeat imaging, and your hand therapist, Ruby Doolan at Extend Rehabilitation, makes any splint you need and guides your return to movement at the right stage. Athletes sometimes choose to keep playing with the fracture and deal with the unhealed piece later, and we will talk through what that means for you.

If the pieces have shifted apart, or the fracture is unstable, we may recommend surgery from the start. One option is removing the hook of bone, which lets you return to your sport relatively quickly. Another is holding the bone together with a small screw, which we may suggest for younger patients to preserve grip strength. We aim to protect the nearby nerve and blood supply during any of these operations. The choice between these paths is genuinely shared: sometimes a splint could work, but the pain or the final position of the bone may not suit your hand or your sport.

Whichever path you take, the early weeks look similar. We will help you manage the pain, and you protect your hand while it heals. Hand therapy with Ruby starts at the right stage, so your grip and movement come back safely. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review.

What to expect

Healing depends on where you are in the story. If your fracture is found early and the pieces sit in their normal position, keeping your hand still in a splint or cast gives the bone its chance to knit. If the fracture is found late, or the pieces have shifted, the bone may never knit on its own. In that case, surgery usually means either a small screw to hold the bone together or removing the hook altogether.

If you have surgery to remove the hook, most people are back to their sport relatively quickly. For high-level amateur athletes, surgery allows return to sport at their preinjury performance level, with normal hand function on testing, less pain, and satisfaction with the result. One professional bowler had satisfactory hand function 2.5 months after the hook was removed. Early and late surgery both lead to return to preinjury levels of activity. Holding the bone together with a screw can also work well, with few problems afterwards, and repair of an unhealed fracture can preserve grip strength and relieve pain completely.

Recovery is a gradual return, not a switch. Your hand will ache at first, and the ache settles over weeks. Grip strength comes back as the hand is used again, guided by your hand therapist. Daily tasks like holding a mug or turning a key get easier as the tendons stop being irritated by the broken piece.

There are honest risks worth knowing. The hook has a poor blood supply, so slow or failed healing is the main concern. If the bone does not knit, the rough edge can rub on your finger tendons. Tendon rupture in the little finger has happened anywhere from 6 months to 25 years after the original injury, and grip strength afterwards averaged 83% of the other hand. If a tendon does snap, the broken hook is removed and smoothed so the tendon can work again. Surgery itself carries a low risk of minor complications. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review.

When to see someone

Seek urgent care if you have an open wound over the injury, bone showing, or an obvious deformity. Go the same day if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement. These signs need an emergency department, not a waiting room.

For everything else, start with your GP. Ask for a specialist review if the pain is not settling, or if swelling, movement or grip are not improving week on week as the bone heals. This injury hides on standard x-rays, so a normal first result does not rule it out. A CT scan finds it 95% of the time, and getting the diagnosis early protects your grip and your tendons later on.

Reviewed by AI synthesis (v2) — pending human review · 15 September 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Hook of hamate fractures are rare injuries [7, 15].
  • The most usual mechanism for hook of hamate fractures is a direct blow to the area of the hook [7, 15].
  • Fractures of the hook of the hamate have been infrequently reported in the literature [2].
  • Hook of hamate fractures with normal standard x-rays may be difficult to diagnose, especially for a nonhand surgeon [1].
  • A specific radiographic view is recommended in addition to standard views in all cases of suspected fractures of the hook of the hamate [8].
  • The incidence of acute hook of hamate fracture in association with high-energy distal fractures in patients undergoing CT evaluation of the wrist is 2.7% [18].
  • Hamate hook fractures can be successfully treated acutely by immediate immobilization [3].
  • Non-displaced acute fractures and delayed union of the hamate hook can be treated successfully by dorsal percutaneous cannulated mini-screw fixation with minimal morbidity and complications [5].
  • The dorsal percutaneous approach is a reliable method that provides safe fixation of non-displaced fractures of the hook of hamate [23].
  • Surgical excision as treatment for hook of hamate fractures is safe and allows a relatively rapid return to play in most cases [4].
  • Surgical excision of the hook of the hamate resulted in good postoperative outcomes with a mean follow-up of 6 years in athletes [19].
  • Early and late surgical excision of the hook of the hamate leads to excellent results with return to preinjury levels of activity [13].
  • Surgical excision of hook of hamate fractures in high-level amateur athletes allows for successful return to sports participation at preinjury performance levels, achievement of normal function as measured by validated objective outcome measures, significant reduction in pain, and high overall patient satisfaction [27].
  • Surgical excision is the treatment of choice for fractures of the hook of the hamate in any athlete, as the incidence of nonunion precludes the use of open reduction internal fixation [30].
  • The treatment of choice for a symptomatic nonunion, and possibly for an acute fracture, appears to be surgical excision of the hook of the hamate [9].
  • Symptomatic partial union of the hook of the hamate fracture in athletes should be managed with excision of the hook of the hamate and repair of the ligament attachments [10].
  • The open carpal tunnel approach is a successful technique for open excision of symptomatic ununited hook of hamate fractures due to its familiarity, ease of performance, excellent visualization, and low morbidity [22].
  • Both surgical procedures appear to yield acceptable outcomes in the treatment of hook of hamate fractures [11].
  • Repair by open reduction and internal fixation for ununited fracture hook of the hamate is feasible and desirable for preservation of grip strength and complete relief of pain [14].
  • In younger patients with nonunion of the hook of the hamate, repair of the nonunion rather than simple excision should be aimed for to preserve grip strength [20].
  • Hook of hamate regeneration can occur after fracture fragment excision [12].
  • The incidence of a hypoplastic hook of the hamate is common in patients with carpal tunnel syndrome [47].

Anatomy & Pathophysiology

Bony Anatomy

  • The hamate consists of a body and a hook (hamulus) [59].
  • The hook of the hamate serves as an attachment site for the transverse carpal ligament [59].
  • The hook of the hamate serves as an origin for the flexor digiti minimi and opponens digiti minimi muscles [59].
  • The distal end of the transverse carpal ligament is located 10 mm from the hook of the hamate [36].
  • The boundaries of Guyon’s canal include the hook of the hamate radially and the pisiform ulnarly [56].

Vascular Supply

  • The extraosseous blood supply to the carpus is provided by terminal branches of the radial, ulnar, and anterior interosseous arteries through dorsal and palmar transverse arterial arches [62].
  • The dorsal intercarpal arch is the largest of the dorsal arches and supplies the distal carpal row [62].
  • The deep palmar arch at the level of the metacarpal bases is consistent and communicates with the dorsal basal metacarpal arch and palmar metacarpal arteries [62].
  • The hamate hook has a poor blood supply, which is a main reason for the increased risk of nonunion [48].
  • The hamate hook is vulnerable to osteonecrosis and nonunion due to its vascularity [3].

Ligamentous Anatomy

  • The capitohamate ligament is a thick ligament with a cross-section of 5 × 5 mm [57].
  • The capitohamate ligament has extensions to the third or fourth metacarpals [57].
  • The distal row of carpal bones is rigid with little motion between its bones due to stout intercarpal ligaments [57].

Biomechanics & Kinematics

  • The hamate is part of the central column of the wrist, which controls flexion-extension of the wrist [60].
  • The hamate is part of the metacolumn in Weber's three-column theory, which includes the triquetrum and hamate [60].
  • The lunate, capitate, hamate, trapezium, and trapezoid function collectively as the "stable central column" in the Sandow et al. model [60].
  • The hamate hook provides a biomechanical advantage for flexor tendon function [43].
  • Cadaveric changes in tendon force after hamate hook excision suggest that power grip may be decreased [43].
  • No significant change in the position of deep or superficial digital flexor tendons relative to the hook of hamate was noted with finger extension or flexion [49].

Pathophysiology & Injury Mechanisms

  • Hook of hamate fractures are traditionally thought to be caused by direct trauma [69].
  • Fracture of the hook of hamate is more likely to result from a fatigue response due to repetitive load applied by adjacent deep flexor tendons [69].
  • Direct pressure of tendons on critical local vessels reduces blood flow, leading to mechanical and vascular effects that create pathological osseous change and weakening [69].
  • These pathological changes predispose to stress fracture and nonunion in repetitive gripping activities [69].
  • High-energy single-impact hamate fractures likely occur in otherwise healthy bone without pre-existing stress response [72].
  • Fractures of the hook of the hamate can occur by direct impact applied to the hamate during a fall on the heel of the hand [48].
  • Fractures of the hook of the hamate can occur by microtraumatism in sports requiring repeated use of a racquet or a bat [48].
  • The growing popularity of golf and other racquet sports has led to an increase in stress fractures of the hamate hook [48].
  • Mobility of the fracture site is a main reason for the increased risk of nonunion of the hamate hook [48].
  • Delayed diagnosis is a main reason for the increased risk of nonunion of the hamate hook [48].
  • Combined fracture of the hook of the hamate and palmar dislocation of the fifth carpometacarpal joint results from a sudden, violent contraction of the flexor carpi ulnaris against a fixed wrist [35].
  • Chronic repetitive wear and fraying of flexor tendons against the rough surface of the hook is the proposed etiology for closed rupture of the flexor tendon [37].
  • The misleading presentation of a hamate hook stress fracture in a professional bowler is related to a new drilling layout of the bowling ball and technical changes during ball release [29].
  • Technical changes in bowling redistribute micro-constraints on the hook of the hamate using an indirect mechanism of injury through ligaments and flexor tendons [29].

Classification

Epidemiology and Mechanism

  • Fractures of the hook of the hamate are rare injuries [7].
  • Hamate hook fracture represents 2% of carpal bone fractures [48].
  • The incidence of acute hook of hamate fracture in association with high-energy distal radius fractures is 2.7% [18].
  • Combined intraarticular fracture of the body and hook of hamate is an extremely rare injury pattern [21].

Diagnostic Challenges

  • Fractures of the hook of the hamate are not seen on standard two or three view wrist examination [26].
  • The similarities between a fracture of the hook of the hamate and other conditions that cause ulnar wrist pain can lead to failure of clinical diagnosis [17].
  • Combined intraarticular fracture of the body and hook of hamate requires a high index of suspicion for diagnosis [21].

Imaging and Physical Examination

  • The carpal tunnel radiographic view should be considered in addition to routine radiographic views for patients with a possible hook of the hamate fracture [6].
  • The hook of hamate pull test is an easy, cheap, sensitive, and specific test that can be readily performed in the clinic to diagnose hook of hamate fractures [25].
  • A CT scan has 95% specificity and 95% accuracy in diagnosing hamulus fractures [33].
  • Pain is provoked by resistive extension of the ring and middle finger PIP joints in the diagnosis of hamulus fracture or nonunion [33].

Clinical Presentation

Diagnostic Challenges and Rarity

  • These fractures are not seen on standard two or three view wrist examination [26].
  • Combined intraarticular fracture of the body and hook of hamate is an extremely rare injury pattern requiring a high index of suspicion for diagnosis [21].
  • Hook of hamate fractures present with similarities to other conditions that cause ulnar wrist pain [17].

Physical Examination Findings

  • Volar tenderness on palpation over the hook of hamate was present in 100% of cases in a study of acute hook of hamate fractures [67].
  • The pull test was painful for all patients in a study of acute hook of hamate fractures [67].
  • Pain over the ulnar-palmar base of the hand should prompt a presumptive diagnosis of fracture of the hook of the hamate until proven otherwise [31].

Imaging and Diagnostic Modalities

  • Lateral trispiral tomography is clearly superior to other diagnostic methods for hamate hook fractures [41].
  • An incidence of 2.7% of acute hook of hamate fracture was identified in association with high-energy distal fractures in patients undergoing CT evaluation of the wrist [18].

Mechanism of Injury

  • Hamate hook stress fractures can result from an indirect mechanism of injury through the ligaments and flexor tendons due to redistributed micro-constraints [29].

Investigations

Clinical Examination

  • Fractures of the hook of the hamate have clinical similarities to other conditions that cause ulnar wrist pain [17].
  • In institutions where this protocol is followed, any patient with pain over the ulnar-palmar base of the hand should have a carpal tunnel view obtained with a presumptive diagnosis of hook of hamate fracture until proven otherwise [31].

Radiography

  • Hook of hamate fractures may be difficult to diagnose on standard x-rays, particularly for non-hand surgeons [1].
  • A specific radiographic view is recommended in addition to standard views for all cases of suspected fractures of the hook of the hamate [8].
  • Fractures of the pisiform and hamulus are not seen on standard two or three view wrist examinations [26].
  • Three variations of the hook of hamate were identified with radiographic evaluation using the carpal tunnel view [80].

Advanced Imaging

  • MRI is the modality of choice for imaging radiographically occult fractures of the hand and wrist [58].
  • Bone marrow edema on MRI may reveal fractures of the carpal bones that are radiographically occult [66].
  • An incidence of 2.7% of acute hook of hamate fracture was identified in association with high-energy distal radius fractures in patients undergoing CT evaluation of the wrist [18].

Treatment

Non-Operative Management

  • Hamate hook fractures diagnosed early may heal with nonoperative management [16].
  • Acute hook of hamate fractures in athletes may be treated with casting [34].
  • Ultrasound treatment might be useful for nonunion of the hook of the hamate caused by repeated stress [46].
  • Low-intensity pulsed ultrasound may be useful in the treatment of ununited fractures of the hook of hamate [50].

Operative Management: Excision

  • Surgical excision as treatment for hook of the hamate fractures is safe and allows a relatively rapid return to play [4].
  • Surgical excision of the hook of the hamate resulted in good postoperative outcomes with a mean follow-up of 6 years [19].
  • Surgical excision remains an effective method of management, with a low risk of minor complications for both acute and chronic hook of hamate fractures in professional baseball players [28].
  • MLB players sustaining hook of hamate fractures can reasonably expect to return to their pre-injury performance levels following operative treatment [71].
  • The open carpal tunnel approach is a successful technique for open excision of symptomatic ununited hook of hamate fractures because of its familiarity, ease of performance, excellent visualization and low morbidity [22].
  • A modified surgical approach through Guyon’s Canal and the proximal ulnar border of the carpal tunnel allows for safe excision of the hook of the hamate [32].
  • The modified approach through Guyon’s Canal and the proximal ulnar border of the carpal tunnel allows direct visualization of the vital structures most at risk, including the motor branch of the ulnar nerve, unlike blind or unilateral approaches [32].
  • The modified approach through Guyon’s Canal and the proximal ulnar border of the carpal tunnel preserves the nerve supply and blood supply to the hypothenar muscles [32].
  • A lateral approach to the hook of hamate for its fracture is believed to replace the conventional volar approach because of its benefits in terms of time, safety, and simplicity [42].
  • Functional recovery of the hand was satisfactory 2.5 months after surgical resection of the hamate’s hook in a professional bowler with a stress fracture [29].

Operative Management: Fixation

  • The cadaveric study confirms that the dorsal percutaneous approach is a reliable method and provides safe fixation of non-displaced fractures of the hook of hamate [23].
  • In younger patients with nonunion of the hook of the hamate, one should aim for the repair of the nonunion rather than simple excision to preserve grip strength [20].
  • A simplified dorsal approach to fracture of the hamate hook with percutaneous fixation with screws avoids damage to the blood supply of the hamate, surrounding soft tissues, and the ulnar nerve [45].
  • A simplified dorsal approach to fracture of the hamate hook with percutaneous fixation with screws preserves important stabilising ligaments [45].

Outcomes and Biomechanics

  • Patient outcomes were good to excellent regardless of the treatment chosen, with minimal pain and good hand functionality [44].
  • The hamate hook provides some biomechanical advantage for flexor tendon function [43].
  • Cadaveric changes in tendon force after hamate hook excision suggest that power grip may be decreased after hamate hook excision [43].

Diagnostic Challenges

  • A specific radiographic view is recommended in addition to standard ones in all cases of suspected fractures of the hook of the hamate [8].
  • Fractures of the hook of the hamate share similarities with other conditions that cause ulnar wrist pain, leading to failure of clinical diagnosis [17].

Nonunion and Healing Complications

  • Hamate hook fractures that are diagnosed early may heal with nonoperative management [16].
  • Symptomatic partial union of the hook of the hamate fracture in athletes should be managed no differently from a symptomatic nonunion [10].
  • In younger patients with nonunion of the hook of the hamate, repair of the nonunion is preferred over simple excision to preserve grip strength [20].
  • Range of motion and grip strengths were equivalent on the operated and unoperated sides following bone grafting for nonunion [24].

Surgical Complications and Outcomes

  • Surgical excision as treatment for hook of the hamate fractures is safe and allows a relatively rapid return to play in most cases [4].
  • Dorsal percutaneous cannulated mini-screw fixation for non-displaced acute fractures and delayed union of the hamate hook is associated with minimal morbidity and complications [5].
  • Both surgical procedures for hook of hamate fractures appear to yield acceptable outcomes [11].
  • The open carpal tunnel approach for excision of symptomatic ununited hook of hamate fractures is associated with low morbidity [22].
  • The dorsal percutaneous approach provides safe fixation of non-displaced fractures of the hook of hamate [23].
  • Surgical excision for acute and chronic hook of hamate fractures in professional baseball players carries a low risk of minor complications [28].

Associated Injuries and Anatomical Variations

  • The incidence of acute hook of hamate fracture in association with high-energy distal radius fractures is 2.7% in patients undergoing CT evaluation of the wrist [18].
  • Preoperative evaluation of the morphology of the hooks may help predict adverse events in cases of hypoplastic hooks undergoing endoscopic carpal tunnel release [47].

Recovery

Non-Operative Management

Operative Management

  • Dorsal percutaneous cannulated mini-screw fixation treats non-displaced acute fractures and delayed union of the hamate hook with minimal morbidity and complications [5].
  • In younger patients with nonunion of the hook of the hamate, repair of the nonunion rather than simple excision is recommended to preserve grip strength [20].
  • Range of motion and grip strengths were equivalent on the operated and unoperated sides following bone grafting of a hook of hamate nonunion [24].

Key Evidence

  • [Paper] Hook of hamate fractures, with normal standard x-rays, may be difficult to diagnose, especially for a nonhand surgeon. [1] (10.1016/j.hcl.2021.06.013)
  • [L4] Fractures of the hook of the hamate have been infrequently reported in the literature. [2] (10.1016/0020-1383(89)90169-1)
  • [L5] The data support the recommendation that hamate hook fractures can be successfully treated acutely by immediate immobilization. [3] (10.1016/0363-5023(93)90405-r)
  • [L4] In most cases, surgical excision as treatment for hook of the hamate fractures is safe and allows a relatively rapid return to play. [4] (10.1016/j.jhsa.2017.06.108)
  • [L4] This pilot study demonstrates that non-displaced acute fractures and delayed union of the hamate hook can be treated successfully by dorsal percutaneous cannulated mini-screw fixation with minimal morbidity and complications. [5] (10.1142/s0218810412970039)
  • [L4] The carpal tunnel radiographic view should be considered in addition to routine radiographic views for patients with a possible hook of the hamate fracture. [6] (10.2519/jospt.2010.0408)
  • [L4] Fractures of the hook of the hamate are rare injuries, with the most usual mechanism being a direct blow to the area of the hook. [7] (10.1016/0266-7681(85)90019-1)
  • [L5] We recommend this view, in addition to the standard ones, in all cases of suspected fractures of the hook of the hamate. [8] (10.1016/s0363-5023(88)80026-1)
  • [L4] The treatment of choice for a symptomatic nonunion, and possibly for an acute fracture, appears to be surgical excision of the hook of the hamate. [9] (10.1016/s0363-5023(88)80107-2)
  • [L4] This condition should be managed no differently from a symptomatic nonunion, with excision of the hook of the hamate and repair of the ligament attachments. [10] (10.1177/03635465030310010201)
  • [L4] Both surgical procedures appear to yield acceptable outcomes in the treatment of hook of hamate fractures. [11] (10.1016/j.jhsg.2023.11.011)
  • [L4] Hook of hamate regeneration can occur after fracture fragment excision. [12] (10.1016/j.jhsg.2024.08.008)
  • [L4] Early and late surgical excision of the hook of the hamate leads to excellent results with return to preinjury levels of activity. [13] (10.1053/j.otsm.2010.03.003)
  • [L5] The author maintains that repair by open reduction and internal fixation for ununited fracture hook of the hamate is not only feasible but also desirable, both for preservation of grip strength and complete relief of pain. [14] (10.1016/0363-5023(89)90032-4)
  • [L4] Fractures of the hook of the hamate are rare injuries, with the most usual mechanism being a direct blow to the area of the hook. [15] (10.1016/0266-7681_85_90019-1)
  • [L4] Our results show that hamate hook fractures that are diagnosed early may heal with nonoperative management. [16] (10.1016/0363-5023(92)90363-t)
  • [L4] These cases are reported to emphasize the similarities of a fracture of the hook of the hamate to other conditions that cause ulnar wrist pain. [17] (10.1016/s0363-5023(85)80258-6)
  • [L4] The series identified an incidence of 2.7% of acute hook of hamate fracture in association with high-energy distal fractures in patients undergoing CT evaluation of the wrist. [18] (10.1177/1753193411436293)
  • [L4] Surgical excision of the hook of the hamate resulted in good postoperative outcomes with a mean follow-up of 6 years. [19] (10.3109/17453679308993670)
  • [L5] In younger patients with nonunion of the hook of the hamate, the author believes one should aim for the repair of the nonunion rather than simple excision to preserve grip strength. [20] (10.1016/s0363-5023(86)80127-7)
  • [L5] Combined intraarticular fracture of the body and hook of hamate is an extremely rare injury pattern requiring a high index of suspicion for diagnosis. [21] (10.1007/s12593-012-0070-2)
  • [Paper] The study highlights the open carpal tunnel approach as a successful technique for open excision of symptomatic ununited hook of hamate fractures, because of its familiarity, ease of performance, excellent visualization and low morbidity. [22] (10.1016/j.injury.2014.05.008)
  • [L5] The cadaveric study confirms that the dorsal percutaneous approach is a reliable method and provides safe fixation of non-displaced fractures of the hook of hamate. [23] (10.1177/1753193421991761)
  • [L4] The range of motion and grip strengths were equivalent on the operated and unoperated sides. [24] (10.1016/s0363-5023(89)80008-5)
  • [L4] The hook of hamate pull test is an easy, cheap, sensitive, and specific test that can be readily performed in the clinic to diagnose hook of hamate fractures. [25] (10.1016/j.jhsa.2010.08.024)
  • [L4] These fractures are not seen on standard two or three view wrist examination. [26] (10.1016/s0736-4679(98)00016-x)
  • [L4] Surgical excision of hook of hamate fractures in high-level amateur athletes allows for successful return to sports participation at preinjury performance levels, achievement of normal function as measured by validated objective outcome measures, significant reduction in pain, and high overall patient satisfaction. [27] (10.1016/j.jhsa.2012.10.011)
  • [L4] Surgical excision remains an effective method of management, with a low risk of minor complications for both acute and chronic hook of hamate fractures in professional baseball players. [28] (10.1016/j.jhsa.2021.03.015)
  • [L5] [29] (10.1016/j.hansur.2016.06.007)
  • [L5] Surgical excision is the treatment of choice for fractures of the hook of the hamate in any athlete, as the incidence of nonunion precludes the use of open reduction internal fixation. [30] (10.1016/j.hcl.2012.05.013)
  • [L5] The author states that in their institution, anyone with pain over the ulnar-palmar base of the hand should have a carpal tunnel view with the presumptive diagnosis of fracture of the hook of the hamate until proven otherwise. [31] (10.1016/s0363-5023(86)80125-3)
  • [L4] This modified approach allows direct visualization of the vital structures most at risk, including the motor branch of the ulnar nerve, unlike blind or unilateral approaches, and preserves the nerve supply and blood supply to the hypothenar muscles. [32] (10.1016/j.jhsa.2019.07.015)
  • [L5] [33] (10.1016/j.jhsa.2013.06.004)
  • [L5] Acute hook of hamate fractures in athletes may be treated with casting or allowed to return to play with nonunion addressed later via excision; definitive treatment for stress fractures is excision. [34] (10.1016/j.hcl.2012.05.012)
  • [L5] These findings suggest that such an injury results from a sudden, violent contraction of the flexor carpi ulnaris against the fixed wrist. [35] (10.1016/s0266-7681(96)80043-x)
  • [L5] The distal end of the transverse carpal ligament was located 10 mm from the hook of the hamate. [36] (10.1016/0363-5023(94)90073-6)
  • [L4] The proposed etiology of the tendon ruptures is chronic repetitive wear and fraying against the rough surface of the hook. [37] (10.1142/s2424835516720164)
  • [L4] Lateral trispiral tomography is clearly superior to other diagnostic methods for hamate hook fractures. [41] (10.1016/0363-5023(88)90217-1)
  • [L5] The authors believe this lateral approach should replace the conventional volar approach because of its benefits in terms of time, safety, and simplicity. [42] (10.1016/0266-7681(86)90028-8)
  • [L5] The hamate hook provides some biomechanical advantage for flexor tendon function and cadaveric changes in tendon force after its excision suggest that power grip may be decreased after hamate hook excision. [43] (10.1053/jhsu.2003.50005)
  • [L4] Patient outcomes were good to excellent regardless of the treatment chosen, with minimal pain and good hand functionality. [44] (10.1177/1753193417729603)
  • [L4] This minimally invasive technique avoids damage to the blood supply of the hamate, surrounding soft tissues, and the ulnar nerve, while preserving important stabilising ligaments. [45] (10.3109/02844310801956714)
  • [L4] Ultrasound treatment might be useful for nonunion of the hook of the hamate caused by repeated stress, and we consider that the ultrasound treatment for nonunion of the hook of the hamate is one option in various treatment methods. [46] (10.1007/s00167-003-0425-0)
  • [L4] The incidence of a hypoplastic hook of the hamate is common in patients with carpal tunnel syndrome, and preoperative evaluation of the morphology of the hooks and indications for endoscopic carpal tunnel release in cases of hypoplastic hooks may help predict adverse events. [47] (10.1016/j.jhsg.2023.12.010)
  • [L5] [48] (10.1097/bth.0b013e31826577f8)
  • [L4] No significant change with finger extension or flexion was noted in either the deep or superficial digital flexor tendons. [49] (10.1142/s2424835519500139)
  • [L5] Based on the results of this case low-intensity pulsed ultrasound may be useful in the treatment of ununited fractures of the hook of hamate. [50] (10.1053/jhsu.2000.jhsu025a0077)
  • [L4] [67] (10.1016/j.jhsa.2019.01.014)
  • [L5] [69] (10.1177/17531934241235803)
  • [L3] MLB players sustaining hook of hamate fractures can reasonably expect to return to their pre-injury performance levels following operative treatment. [71] (10.1123/jsr.2017-0071)
  • [L5] [72] (10.1177/17531934241304249)
  • [L4] Three variations of the hook of hamate were identified with radiographic evaluation using the carpal tunnel view. [80] (10.1016/j.jhsa.2005.05.018)

References

[1] Hook of Hamate Fractures. Hand Clinics. 2021. DOI: 10.1016/j.hcl.2021.06.013

[2] Fractures of the hook of the hamate. Injury. 1989. DOI: 10.1016/0020-1383(89)90169-1

[3] Hook of hamate vascularity: Vulnerability to osteonecrosis and nonunion. The Journal of Hand Surgery. 1993. DOI: 10.1016/0363-5023(93)90405-r

[4] Return to Play and Complications After Hook of the Hamate Fracture Surgery. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.108

[5] DORSAL PERCUTANEOUS CANNULATED MINI-SCREW FIXATION FOR FRACTURES OF THE HAMATE HOOK. Hand Surgery. 2012. DOI: 10.1142/s0218810412970039

[6] Hook of the Hamate Fracture. Journal of Orthopaedic & Sports Physical Therapy. 2010. DOI: 10.2519/jospt.2010.0408

[7] Fractures of the hook of the hamate. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1985. DOI: 10.1016/0266-7681(85)90019-1

[8] Radiographic evaluation of the hook of the hamate: A new technique. The Journal of Hand Surgery. 1988. DOI: 10.1016/s0363-5023(88)80026-1

[9] Excision of the hook of the hamate: A retrospective survey and review of the literature. The Journal of Hand Surgery. 1988. DOI: 10.1016/s0363-5023(88)80107-2

[10] Symptomatic, Partial Union of the Hook of the Hamate Fracture in Athletes. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310010201

[11] Surgical Management of Hook of Hamate Fractures: A Systematic Review of Outcomes. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2023.11.011

[12] Hook of Hamate Regrowth After Surgical Excision: A Report of Two Cases. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.08.008

[13] Hook of the Hamate Fractures. Operative Techniques in Sports Medicine. 2010. DOI: 10.1053/j.otsm.2010.03.003

[14] Fracture of hamate hook. The Journal of Hand Surgery. 1989. DOI: 10.1016/0363-5023(89)90032-4

[15] Fractures of the Hook of the Hamate. Journal of Hand Surgery. 1985. DOI: 10.1016/0266-7681_85_90019-1

[16] Nonoperative treatment of acute hamate hook fractures. The Journal of Hand Surgery. 1992. DOI: 10.1016/0363-5023(92)90363-t

[17] Fractures of the hook of the hamate—A failure of clinical diagnosis. The Journal of Hand Surgery. 1985. DOI: 10.1016/s0363-5023(85)80258-6

[18] Concomitant high-energy fractures of the distal radius and hook of hamate. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193411436293

[19] Fractures of the hook of the hamate in athletes: 8 cases followed for 6 years. Acta Orthopaedica Scandinavica. 1993. DOI: 10.3109/17453679308993670

[20] Fracture of the hook of the hamate. The Journal of Hand Surgery. 1986. DOI: 10.1016/s0363-5023(86)80127-7

[21] Combined Intraarticular Fracture of the Body and the Hook of Hamate: An Unusual Injury Pattern. Journal of Hand and Microsurgery. 2013. DOI: 10.1007/s12593-012-0070-2

[22] Surgical excision of ununited hook of hamate fractures via the carpal tunnel approach. Injury. 2014. DOI: 10.1016/j.injury.2014.05.008

[23] Safety and reliability of the dorsal percutaneous approach for non-displaced hook of hamate fracture: an anatomical study. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/1753193421991761

[24] Nonunion of the hook of the hamate: An argument for bone grafting the nonunion. The Journal of Hand Surgery. 1989. DOI: 10.1016/s0363-5023(89)80008-5

[25] Hook of Hamate Pull Test. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.08.024

[26] Pisiform and Hamulus Fractures: Easily Missed Wrist Fractures Diagnosed on a Reverse Oblique Radiograph. The Journal of Emergency Medicine. 1998. DOI: 10.1016/s0736-4679(98)00016-x

[27] Outcomes of Hook of Hamate Fracture Excision in High-Level Amateur Athletes. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.011

[28] Hook of Hamate Fractures in Major and Minor League Baseball Players. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.03.015

[29] Hamate hook stress fracture in a professional bowler: Case report of an unusual causal sport. Hand Surgery and Rehabilitation. 2017. DOI: 10.1016/j.hansur.2016.06.007

[30] Treatment of Fracture of Hook of the Hamate in Baseball Players. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.05.013

[31] Fractures of the hook of the hamate. The Journal of Hand Surgery. 1986. DOI: 10.1016/s0363-5023(86)80125-3

[32] A Modified Surgical Approach Through Guyon’s Canal and the Proximal Ulnar Border of the Carpal Tunnel Allows for Safe Excision of the Hook of the Hamate. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.07.015

[33] Hook of Hamate Fractures. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.06.004

[34] Hook of Hamate and Pisiform Fractures in Basketball and Hockey Players. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.05.012

[35] Combined Fracture of the Hook of the Hamate and Palmar Dislocation of the Fifth Carpometacarpal Joint. Journal of Hand Surgery. 1996. DOI: 10.1016/s0266-7681(96)80043-x

[36] Clinical location of hook of hamate: A technical note for endoscopic carpal tunnel release. The Journal of Hand Surgery. 1994. DOI: 10.1016/0363-5023(94)90073-6

[37] Closed Rupture of the Flexor Tendon Secondary to Sclerosis of the Hook of the Hamate: A Report of Two Cases. The Journal of Hand Surgery (Asian-Pacific Volume). 2016. DOI: 10.1142/s2424835516720164

[41] Fracture of the hamate hook. The Journal of Hand Surgery. 1988. DOI: 10.1016/0363-5023(88)90217-1

[42] Lateral approach to the hook of hamate for its fracture. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1986. DOI: 10.1016/0266-7681(86)90028-8

[43] Biomechanical evaluation of flexor tendon function after hamate hook excision. The Journal of Hand Surgery. 2003. DOI: 10.1053/jhsu.2003.50005

[44] Diagnosis and management of hook of hamate fractures. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417729603

[45] Simplified dorsal approach to fracture of the hamate hook with percutaneous fixation with screws. Journal of Plastic Surgery and Hand Surgery. 2010. DOI: 10.3109/02844310801956714

[46] Ultrasound treatment of nonunion of the hook of the hamate in sports activities. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-003-0425-0

[47] Anatomic Variation of the Hamate Hook as a Potential Risk in Endoscopic Carpal Tunnel Release. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2023.12.010

[48] Hamate Hook Nonunion Treated With a Hook Plate. Techniques in Hand & Upper Extremity Surgery. 2012. DOI: 10.1097/bth.0b013e31826577f8

[49] Sliding Position of the Flexor Tendons Relative to the Hook of Hamate in CT Scans. The Journal of Hand Surgery (Asian-Pacific Volume). 2019. DOI: 10.1142/s2424835519500139

[50] Treatment of ununited fracture of the hook of hamate by low-intensity pulsed ultrasound: A case report. The Journal of Hand Surgery. 2000. DOI: 10.1053/jhsu.2000.jhsu025a0077

[56] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > FRACTURES AND DISLOCATIONS OF THE DISTAL AND MID-FOREARM.

[57] Aaos Comprehensive Orthopaedic Review 3. Carpal Instability* > II. Anatomy and Biomechanics (See Chapter 92).

[58] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Imaging: Advances in Imaging of the Hand and Upper Extremity > Magnetic Resonance Imaging.

[59] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Hand and Wrist > VII. The Wrist.

[60] Green S Operative Hand Surgery. WRIST BIOMECHANICS > Carpal Kinematics.

[62] Campbell S Operative Orthopaedics 4 Volume Set. NERVE INJURIES AT THE LEVEL OF THE HAND AND WRIST > CIRCULATION.

[66] Campbell S Operative Orthopaedics 4 Volume Set. WRIST AND ELBOW.

[67] Minimally Invasive Fixation With a Volar Approach Using a Cannulated Compression Screw for Acute Hook of Hamate Fractures. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.01.014

[69] The aetiology of fracture and nonunion in the hook of the hamate. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241235803

[71] Performance Outcomes After Hook of Hamate Fractures in Major League Baseball Players. Journal of Sport Rehabilitation. 2018. DOI: 10.1123/jsr.2017-0071

[72] Re: Campbell FC, Jones SW, Campbell DA. The aetiology of fracture and nonunion in the hook of the hamate. J Hand Surg Eur. 2024, 49: 1172-8. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241304249

[80] Anatomic Variations of the Hook of Hamate and the Relationship to Carpal Tunnel Syndrome. The Journal of Hand Surgery. 2005. DOI: 10.1016/j.jhsa.2005.05.018

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.